<div id="postResults"></div>
{clni_form}
<input type="submit" value="Update" />
<div style="clear: both;"></div>
<br />
<table>
<tr>
<td><b>Illness</b>:</td>
<td>
{input type="string" name="family_history_disease_illness"}
</td>
</tr>
<tr>
<td><b>Relative</b>:</td>
<td>
{input type="string" name="family_history_disease_relative" size="20"}
</td>
</tr>
<tr>
<td><b>Comment</b>:</td>
<td>
{input type="string" name="family_history_disease_comment" size="40"}
</td>
</tr>
</table>
</form>
